Provider Demographics
NPI:1710919816
Name:OPTICAL DISPENSARY INC
Entity Type:Organization
Organization Name:OPTICAL DISPENSARY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-331-7917
Mailing Address - Street 1:117 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1503
Mailing Address - Country:US
Mailing Address - Phone:315-331-7917
Mailing Address - Fax:315-331-7917
Practice Address - Street 1:117 E UNION ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1503
Practice Address - Country:US
Practice Address - Phone:315-331-7917
Practice Address - Fax:315-331-7917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004325156FX1800X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017510226OtherBC/BS PROVIDER#
NY01782085Medicaid
NY103080CTOtherPREFERRED CARE PROVIDER#